Simple bone cysts: better with age?

Percutaneous calcium sulfate injection versus localized scrape bone grafting: clinical effect comparison in titanium elastic nail treatment of pathological fracture of proximal humerus caused by unicameral bone cysts in children

Objective

A retrospective study was conducted to compare the mid-term clinical efficacy between percutaneous calcium sulfate injection (PCSI) and localized scrape bone grafting (LSBG) in using titanium elastic nails treat humerus pathologic fractures caused by unicameral bone cysts in children.

Methods

Humerus pathologic fracture patients with unicameral bone cysts in our pediatric orthopedic department from January 2015 to January 2020 were retrospectively analyzed. Patients were divided into two groups, namely the PCSI group and the LSBG group, based on the type of bone grafting material they received. Preoperative assessments were made in both groups using the Cyst Index and Cyst activity. During the perioperative phase, assessments were made regarding operative time, bleeding, postoperative VAS scores, and the frequency of reoperation within 2 years. Clinical outcomes were evaluated using the Capanna scale at the last follow-up, and the occurrence of re-fractures during the follow-up period.

Results

A total of 22 patients were included, with a mean follow-up duration of 33.5 ± 5.8 months. No significant differences were found between the two groups in terms of Cyst Index and Cyst activity before the operation. The operative time, bleeding, and postoperative VAS scores in the PCSI group were found to be lower than those in the LSBG group (P < 0.05). The PCSI group also showed a higher frequency of reoperation within 2 years compared to the LSBG group (P < 0.05). However, no significant differences were observed between the two groups in terms of Capanna scale scores at the last follow-up and the incidence of re-fractures during follow-up.

Conclusions

Both titanium elastic nails (TEN) combined with PCSI or LSBG were found to be safe and effective treatments for humerus pathologic fractures caused by unicameral bone cysts in children. PCSI is considered as a less invasive option with shorter operative times, less bleeding, and reduced postoperative pain, although it comes with the risk of multiple injections. On the other hand, LSBG is considered as a more invasive option for the treatment of active bone cysts but is associated with a lower recurrence rate.

Treatment of a calcaneal unicameral bone cyst by percutaneous CT-guided cement injection using a double-needle technique: A case report

Simple bone cysts (SBCs) are benign cavitary lesions that most commonly affect adolescent males in the first 2 decades of life. They are mainly asymptomatic but can manifest with pain or pathological fractures. Despite numerous proposed methods for managing calcaneal SBCs, the optimal approach toward these lesions remains controversial. Herein, we report a case of a 16-year-old girl with a calcaneal SBC. On local examination, tenderness was the only noteworthy sign. In an outpatient setting, under conscious sedation, 2 interosseous needles were simultaneously inserted into the cyst under the guidance of CT fluoroscopy. Without aspiration, a radiopaque bone cement mixture was injected into the cyst from 1 needle until serosanguineous fluid efflux from the second needle ceased. Over a 2-year follow-up period, the patient recovered without any complications. This novel technique has the potential to be used as a feasible and minimally invasive approach in the management of symptomatic unicameral calcaneal bone cysts.

Management of Calcaneal Cysts in the Pediatric Population: A Review

Cysts of the bone are a common pathology that, although benign, are frequently treated because of their tendency to compromise the integrity of affected bone. Two common entities are unicameral bone cysts and aneurysmal bone cysts. Although these are two distinct pathologies, they are treated similarly and thus will be discussed in tandem. The optimal treatment of calcaneal bone cysts in pediatric patients has long been debated among orthopaedic surgeons because of the relatively small number of cases and varied results within the literature. Currently, there are three lines of thought regarding treatment: observation, injection, and surgical intervention. When considering which course of treatment is best for an individual patient, the surgeon must consider the fracture risk without treatment, the risk of complications with treatment, and the recurrence rate with each treatment approach. There are limited data on pediatric calcaneal cysts specifically. Still, there are much data concerning simple bone cysts of long bones in the pediatric population and calcaneal cysts in the adult population. Because of the lack of literature on the subject, there is a need for a review of the available literature and a consensus on the approach to treating calcaneal cysts in the pediatric population.

Functional limitations caused by simple bone cysts

PURPOSE

Relatively little is known about the impact of benign bone lesions on function. The aim of this study was to create a more complete understanding of the impact of functional disability from simple bone cysts (SBCs) by combining qualitative and quantitative methods.

METHODS

This study followed a convergent parallel mixed methods design. The quantitative arm included 130 children with SBC and used the Activities Scale for Kids (ASK) to measure physical function. In the qualitative arm ten children and their parents participated in interviews related to activity participation and interactions with their physical and social environments. The two data sets were analyzed independently and then the results were integrated.

RESULTS

The ASK demonstrated 35% of children achieving the maximum score. In total, 65% of children responded "I had no medical needs" confirming that SBC, while being present throughout childhood, is largely perceived as not a chronic illness. Qualitatively most children reported minimal or no changes in activity participation but reported thinking about being more cautious during play, confirming that SBC affects effort not participation in play.

CONCLUSION

The diagnosis of SBC did not have a significant impact on physical function, but did alter children's thoughts about physical activity participation. This finding suggests that physical function scores may have unappreciated ceiling effects. Outcome tools that combine both illness perceptions and physical function may help to better assess functional outcomes of SBC.

LEVEL OF EVIDENCE

III.

Comparative efficacy and safety profile for the treatment of humeral bone cysts in children: curettage and mixed bone grafting either with or without elastic intramedullary nailing

Purpose

The primary aim of our study was to evaluate the comparative efficacy and safety profile of curettage and mixed bone grafting without instrument or with elastic intramedullary nailing in the treatment of humeral bone cyst in children.

Methods

Our retrospective study included a total of 48 children harboring humeral bone cyst in our hospital from August 2012 to February 2019. The patients enrolled were divided into elastic nailing group with the application of elastic intramedullary nailing (n = 25) and control group without using instrument (n = 23) during the management of curettage and mixed bone grafting. The following medical outcomes of the two groups were monitored and recorded: the amount of intraoperative blood loss, operation time and postoperative full weight-bearing time, in addition to postoperative clinical effects after 1 year, the function and pain level of shoulder joint before and 1, 3, 6, 9, 12, and 16 months after operation. Follow-up radiographic outcomes were reviewed to observe bone healing, local recurrence and internal fixation loosening, and other postoperative complications.

Results

The clinical curative effect of the elastic nailing group was higher than that of the control group 16 months after operation (96.00% > 73.91%, P < 0.05). The intraoperative blood loss and postoperative full weight-bearing time in the elastic nailing group were less than those in the control group (P < 0.05), but the operation time was statistically insignificant between the two groups (P > 0.05). Before operation, the shoulder joint function of the two groups was comparable (P > 0.05), while the function showed remarkably better outcome in the elastic nailing group than control group 1 to 16 months after operation (P < 0.05). Before operation, the pain level of the two groups was comparable (P > 0.05), while 1 to 16 months after operation, the pain level of the elastic nailing group was significantly lower than that of the control group (P < 0.05). Patients in both groups were followed up for 16 months. Mixed bone grafting fusion was indicated by imaging CT and X-ray during the follow-up period, with an average fusion time of 11.3 ± 1.2 months (range, 8–16 months). Three months after operation, there was 1 case of incomplete pathological fracture in the control group, while no related complications occurred in the elastic nailing group. Moreover, no tumor recurrence was observed in the two groups. The two groups were comparable in terms of the incidence of complications (P > 0.05).

Conclusion

Children with humeral cyst treated with curettage and mixed bone grafting with the additional use of elastic intramedullary nailing exerted superior results to those without using instrument as there are beneficial outcomes and safety profile and no complications.

What's New in Pediatric Orthopaedic Tumor Surgery

BACKGROUND

Pediatric Orthopaedic Oncology is a developing subspecialty within the field of Pediatric Orthopaedics. Traditionally, the field of Orthopaedic Oncology has been focused on the skeletally mature individual, and the research tends to be all encompassing rather than truly evaluating isolated populations. The purpose of this review is to summarize the most clinically relevant literature in the field of Pediatric Orthopaedic Oncology over the last 6 years.

METHODS

We evaluated the PubMed database utilizing keywords for pediatric orthopaedic oncology: sarcoma, osteosarcoma, Ewing sarcoma, bone cyst. In additionally, we further broadened our search by searching for relevant articles in the contents sections of major orthopaedic surgery journals that routinely publish both pediatric and orthopaedic oncology literature. In keeping with "What's New," we selected the most clinically relevant articles published in the last 6 years from January 1, 2014 through February 2020. Basic science and systemic therapies literature was widely reviewed and the research and clinical trials most relevant to pediatric sarcoma and neoplastic processes found in the pediatric population were included.

RESULTS

Our search yielded 60 articles that met general criteria, from which 14 were determined to be most relevant to the goals of this paper. Of the papers presented in this review, there were papers related to management of benign tumors/tumor-like conditions, bone cysts, limb salvage procedures, and amputation procedures. Ultimately included in the review were 5 studies related to limb salvage, 4 related to bone cysts, 1 related to multiple hereditary exostoses, 2 related to osteofibrous dysplasia, 1 related to chondroblastoma, and 1 discussing cementation in skeletally immature patients. They were level III, IV, and V studies. Basic science and systemic therapies literature was widely reviewed and the research and clinical trials most relevant to pediatric sarcoma and neoplastic processes found in the pediatric population were included. Our search of the basic science and systemic therapies literature yielded 19 sources were found to be pertinent to our aims and 18 of those sources were published between 2015 and 2020.

CONCLUSIONS

There are many, varied, and creative procedures in the realm of limb salvage, though there remains a lack of high-level evidence to support some of the more novel procedures. In regards to benign bone tumors, despite a more solid base of literature, there still does not seem to be consensus as to the best treatment. In particular, there continue to be many schools of thought on the treatment of benign bone cysts. Research in the basic science arena and systemic therapies are advancing in exciting ways in regards to pediatric sarcoma. Orthopaedic oncologic research specific to the pediatric population overall continues to be impeded by low sample sizes and inadequate levels of evidence, which limits the ability of surgeons to draw definitive conclusions from the literature.

Current Trends and Variations in the Treatment of Unicameral Bone Cysts of the Humerus: A Survey of EPOS and POSNA Members

BACKGROUND

A variety of treatment methods have so far been described for unicameral bone cysts (UBC). However, to the best of our knowledge, no particular consensus has yet been reached on when to operatively treat a patient with a humeral UBC. Therefore, members of the European Pediatric Orthopedic Society (EPOS) and Pediatric Orthopedic Society of North America (POSNA) were surveyed to characterize current treatment preferences.

METHODS

An online electronic questionnaire was sent out to all registered EPOS and POSNA members. The survey comprised 45 questions related to the diagnosis, treatment, and follow-up characteristics of patients with UBCs of the humerus. Particular questions related to the nonoperative or surgical treatment of pathologic proximal humerus and humeral shaft fractures were also included.

RESULTS

In total, 444 participants (132 EPOS and 292 POSNA members) responded, of whom 400 were actively involved in UBC treatment. The preferred diagnostic modalities to confirm the diagnosis of a UBC in the humerus were radiographs (88%), MRI in cases of questionable diagnosis (58%) or CT scan (8%). For painless UBCs 67% prefer no treatment at all except when the fracture risk is deemed high (then 53% recommend surgery); 71% of respondents would treat painful UBCs with surgery. Most common surgical techniques comprise curettage (45%), artificial bone substitutes (37%), corticosteroid injection (29%), or intramedullary stabilization (eg, rodding; 24%).Fractured, nondisplaced and mildly displaced proximal humerus UBCs and mildly displaced pathologic humerus shaft fractures are all preferably treated nonoperatively (94%, 91%, 83%, respectively). Severely displaced pathologic proximal humerus fractures are treated less often conservatively (36%) than surgically (40%), and severely displaced humerus shaft fractures are preferably treated surgically (63%) by intramedullary stabilization (60%).

CONCLUSIONS

There is great variation among EPOS and POSNA members with regards to the diagnosis and treatment of UBCs in the humerus. Although some consensus on general treatment principles is seen, specific surgical treatment indications vary.Prospective randomized-controlled studies are needed to evaluate the outcomes of the different surgical approaches compared with nonoperative strategies.

LEVEL OF EVIDENCE

Level V-expert opinion.

TREATMENT OF UNICAMERAL BONE CYSTS IN CHILDREN: A COMPARATIVE STUDY

Unicameral bone cysts (UBC) are benign bone tumor-like lesions. Mostly they are located in the metaphyseal-diaphyseal region of long bones in children and adolescents. The etiology of UBC is still unclear. There is no consensus about the protocol of UBC treatment. The aim of this study was to evaluate the effectiveness of three different techniques for the treatment of UBC. This study included 129 pediatric patients with UBC treated at University Children’s Hospital in Belgrade during the 8-year period. The mean follow up was 7.14 years. The following parameters were observed: gender, age, site, length of cyst, cyst index, cortical thickness, presentation of pathologic fracture, healing of cyst, treatment complications and length of hospitalization. These parameters were correlated to three treatment modalities, i.e. intracystic methylprednisolone acetate injection (group 1), curettage with bone grafting (group 2) and osteoinductive procedure using demineralized bone matrix (group 3). We found statistically significant differences in healing of the cysts and length of hospital treatment between groups 1 and 2, and between groups 2 and 3. In conclusion, complete healing of UBC can be achieved only using open surgery procedure. Intracystic methylprednisolone acetate instillation can be considered a good option for initial treatment of UBC.

Comparison of three surgical treatment options for unicameral bone cysts in humerus

Treatment of unicameral bone cysts (UBC) in the humerus with drainage screws is scarcely reported in the literature. The aim of this retrospective study was to compare drainage screws and alternative treatment methods with respect to the number of required surgical procedures to achieve sufficient UBC healing, postoperative fractures/recurrences/complications, and radiological outcome. Medical archives of two tertiary orthopedic referral centers were screened for all patients who were treated surgically for humeral UBC in the period 1991-2015 with a histologically/cytologically confirmed diagnosis. Sex, age, all surgical procedures, fractures, complications, recurrences, and the final radiological outcome were compared between patients treated with drainage screws, elastic intramedullary nails, or curettage with optional grafting. The study included 106 operated patients with a mean age of 10.3 years, with a mean follow-up of 5.7 years. The average number of UBC-related surgical procedures in sex-matched and age-matched treatment groups was 2.7 with drainage screws, 2.8 with intramedullary nails, and 3.5 with curettage/grafting (P=0.54). Intramedullary nails (odds ratio 0.20) and older age (odds ratio for each year 0.83) predicted a lower risk of postoperative UBC recurrence. Patients with drainage screws had the highest UBC recurrence rates and the lowest rates of changed initial treatment method. There was no difference between the treatment groups in the postoperative fracture rate, complications, or the final radiological outcome. UBC treatment in the humerus therefore requires approximately three surgical procedures, irrespective of the treatment modality chosen. Adding an elastic intramedullary nail to a humeral UBC cyst may reduce recurrence risk and prevent further fractures. Level of Evidence: Level III - therapeutic retrospective comparative study.

A comparative study for the treatment of simple bone cysts of the humerus: open curettage and bone grafting either without instrumentation or with intramedullary nailing

Functional and radiographic outcomes, in addition to complication and reoperation rates of open curettage and grafting without instrumentation or with intramedullary nailing, in the treatment of simple bone cysts (SBCs) of the humerus were compared. Thirty-seven children [25 males, 12 females; median age=9.5 years (range, 3-17 years)] with humeral SBC were treated with curettage and grafting without instrumentation (group 1, 21 patients) or with intramedullary nailing (group 2, 16 patients). The pathological fracture rate was 85.7% in group 1 and 87.5 in group 2. The follow-up duration ranged from 26 to 85 months. The average last follow-up Musculoskeletal Tumor Society functional scores for groups 1 and 2 were 28.9 and 29.5 (P>0.05). Higher, but statistically insignificant (P>0.05), complete or significant partial radiographic healing rates were achieved in group 2 (100%) compared with group 1 (76.2%). The overall complication rate of the entire study population was 21.6% (19%; 4/21 in group 1; 25%; 4/16 in group 2). The reoperation rates for groups 1 and 2 were 9.5% (2/21; one for partial cyst healing, one for recurrence) and 56.25% (9/16; one for surgical complication, eight for implant removal). Surgical intervention is indicated for selected patients with SBCs. Even though perfect functional results were possible with open curettage and grafting, continuous intramedullary decompression with elastic nails led to a higher radiographic healing rate in the treatment of humeral SBCs. Open curettage and grafting with or without intramedullary nailing was associated with a high number of complications, but the rate of reoperation for complications was very low.

Solitary bone cyst: a comparison of treatment options with special reference to their long-term outcome

Background

Solitary bone cysts (SBC) are benign, tumor-like lesions, which most frequently occur in the proximal metaphyseal-diaphyseal region of the humerus and femur of children and adolescents. The lack of a clear pathoetiology has impeded the development of treatment strategies. Up to date there is no consensus or official guideline for when and how treat SBC. The purpose of this study was to evaluate the effectiveness and the longterm clinical outcome of the treatment of SBC. Different techniques have been used dependant of the site of lesion, dimension, medical history and activity status.

Methods

135 skeletal immature patients with a solitary bone cyst were included. A follow up of 36 months or more was available for all patients. 22 patients were treated conservatively. All the other patients had at least one surgical intervention. The following four surgical treatment modalities were used: injection of methylprednisolon acetat (steroids), intramedullary nailing (IN), IN + steroids and curettage plus bone grafting.

Results

There was no significant difference between the treatment groups with respect to secondary fractures, function, pain, or complications. In the individual groups the failure rate after initial treatment was 36,6 % with steroids, 50 % with intramedullary nailing, 21,4 % with intramedullary nailing plus steroids and none in the remaining group.

Conclusion

Steroid injection remains a reliable method for treating solitary bone cysts owing to its low invasiveness. To prevent fractures and allow a full weight bearing, internal fixation in combination with methylprednisolon acetat injections seems to be the most favorable in weight bearing bones.